Shunt For Hydrocephalus Research Articles

Automated ventricular segmentation and shunt failure detection using convolutional neural networks.

While ventricular shunts are the main treatment for adult hydrocephalus, shunt malfunction remains a common problem that can be challenging to diagnose. Computer vision-derived algorithms present a potential solution. We designed a feasibility study to see if such an algorithm could automatically predict ventriculomegaly indicative of shunt failure in a real-life adult hydrocephalus population. We retrospectively identified a consecutive series of adult shunted hydrocephalus patients over an eight-year period. Associated computed tomography scans were extracted and each scan was reviewed by two investigators. A machine learning algorithm was trained to identify the lateral and third ventricles, and then applied to test scans. Results were compared to human performance using Sørensen-Dice coefficients, calculated total ventricular volumes, and ventriculomegaly as documented in the electronic medical record. 5610 axial images from 191 patients were included for final analysis, with 52 segments (13.6% of total data) reserved for testing. Algorithmic performance on the test group averaged a Dice score of 0.809 ± 0.094. Calculated total ventricular volumes did not differ significantly between computer-derived volumes and volumes marked by either the first reviewer or second reviewer (p > 0.05). Algorithm detection of ventriculomegaly was correct in all test cases and this correlated with correct prediction of need for shunt revision in 92.3% of test cases. Though development challenges remain, it is feasible to create automated algorithms that detect ventriculomegaly in adult hydrocephalus shunt malfunction with high reliability and accuracy.

Levodopa-resistant parkinsonism developing after ventriculoperitoneal shunting for obstructive hydrocephalus and improving after endoscopic third ventriculostomy, with specific consideration of brainstem morphology: illustrative case.

Parkinsonism has been reported in patients with obstructive hydrocephalus (OH) following ventriculoperitoneal shunting (VPS). While levodopa works well, some cases are drug resistant. A few case series have reported that endoscopic third ventriculostomy (ETV) is beneficial, though its mechanism remains unclear. The use of a pathophysiology-reflected marker can aid in the diagnosis and treatment strategy. The authors report a case of parkinsonism due to OH after VPS that improved after ETV in a patient taking levodopa, which was subsequently discontinued. A 52-year-old man who had undergone VPS for OH caused by aqueductal stenosis with a tectal tumor presented with severe consciousness disturbance due to acute hydrocephalus and levodopa-refractory parkinsonism after multiple episodes of shunt malfunction. Magnetic resonance imaging showed an elevation of the floor of the third ventricle. ETV was performed to stabilize the pressure imbalance across the stenosis, and his parkinsonism symptoms improved after long-term rehabilitation, resulting in levodopa discontinuation. His pontomesencephalic angle, the angle between the anterior surface of the midbrain and upper surface of the pons in the midline of the sagittal plane, was significantly decreased. The focus in such cases should be on the essence of the pathophysiology for improving the symptoms rather than on easy-to-understand indicators such as ventricle size. https://thejns.org/doi/10.3171/CASE2429.

18F-FDG brain PET: a metabolic predictive factor for gait improvement after cerebrospinal fluid shunting in normal pressure hydrocephalus?

The pathophysiology of normal pressure hydrocephalus (NPH) has not been fully elucidated. Treating NPH with cerebrospinal fluid shunts to improve gait disturbances may have some risks and inconsistent benefits. No clear predictive factor has been identified thus far. This preliminary study aimed to evaluate the predictive value of preoperative brain 18F-FDG positron emission tomography (PET) on overall gait response in patients with NPH. Sixteen patients with NPH who underwent 18F-FDG PET before shunt surgery between 2012 and 2022 were included retrospectively and separated into two groups based on their gait response one year after surgery: responders (R) or nonresponders (NR). Brain glucose metabolism was assessed using visual and semiquantitative analyses using SPM8 software (Welcome Department of Cognitive Neurology, University College, London, UK). Five regions of interest were selected: global cortex, cerebellum, thalamus, striatum, and midbrain. Visual interpretation showed more frequent hypometabolism of the striatum, thalamus and global cortex in NR. None of the patients showing hypometabolism of these regions were R. Based on these results, the visual interpretation allowed us to identify 3/8 NR and 8/8 R. Semiquantitative analysis confirmed significantly lower thalamic metabolism in the NR group (P=0.037) and a trend towards lower metabolism of the striatum (P=0.075) with an area under the curve of 0.77 for thalamic metabolism to discriminate between R and NR. This preliminary study using brain 18F-FDG PET suggests that reduced brain metabolism in the thalamus and striatum along with cortical hypometabolism may be associated with poorer gait response to CSF shunting in normal pressure hydrocephalus (NPH). Although these findings suggest that preoperative brain 18F-FDG PET could potentially aid in selecting appropriate candidates for shunt surgery, further research with larger sample sizes is needed to confirm these results.

Individualized surgical management of acute intracranial infection-associated hydrocephalus

Objective: This study aims to discuss and summarize surgical treatments for acute intracranial infections with hydrocephalus as a supplement to antibiotic treatment. Methods: A total of 29 patients diagnosed with acute intracranial infection associated with hydrocephalus were divided into three groups for comparison and analysis of surgical interventions and outcomes. Results: In this study, 29 patients in one group underwent surgical treatment, while 28 received various forms of external cerebrospinal fluid (CSF) drainage, with a maximum of 5 drainage procedures. Additionally, 6 patients had Ommaya reservoir implantation, 6 had debridement, and 11 had a hydrocephalus shunt. Among the five patients in Group 1, all underwent shunt device extubation. The statistical analysis revealed no significant difference in surgical modes between the groups, but the outcomes did show a statistically significant difference (χ2 = 6.433, P = 0.040). Conclusion: Individualized and multiple surgeries are needed for acute intracranial infection associated with hydrocephalus. In cases where the infection is secondary to a shunt, the primary surgical approach involves removing the shunt device. In situations where the infection is linked to hydrocephalus following different craniotomies, addressing scalp infection, cerebrospinal fluid leakage, and skull defects is essential. In instances of community-acquired intracranial infection associated with hydrocephalus, continuing drainage of cerebrospinal fluid is imperative.

Intraventricular Peritoneal Shunt for Obstructive Hydrocephalus Caused by Cavernous Hemangioma of the Aqueduct of Sylvius.

Intraventricular Peritoneal Shunt for Obstructive Hydrocephalus Caused by Cavernous Hemangioma of the Aqueduct of Sylvius.

Assessing the Quality of Life in Hydrocephalic Children: A Study from Tertiary Care Hospitals in Pakistan.

Hydrocephalus is a neurological disease with higher prevalence in the pediatric population, often managed by placing a shunt. This hollow tube drains excess cerebrospinal fluid from the brain to other body parts, resulting in several complications, including neurological and psychometric manifestations and a compromised quality of life (QoL). This study aimed to evaluate QoL in patients with hydrocephalus shunt placement within the pediatric population. This prospective observational study was conducted in two major Pakistani tertiary care hospitals. A total of 100 subjects were enrolled, of which 52 were found eligible. A validated questionnaire, Hydrocephalus Outcome Questionnaire, was used to evaluate patients' QoL. This study included pediatric patients with a mean age of 6.54 years and a standard deviation of ± 2.64. The male-to-female ratio was 27:25; 2% of patients had congenital or tumor-induced hydrocephalus, while cases of meningitis, encephalocele, and encephalitis accounted for 8, 4, and 2%, respectively. Myelomeningocele had the highest prevalence at 16%. The overall health scores range from 0.39 to 0.51. Social, cognitive, and physical health scores have mean values of 0.54, 0.50, and 0.48, respectively. The minimum physical health score is 0.17, indicating the most significant impact of hydrocephalus on physical function. This study highlights variations in hydrocephalus severity among pediatric patients, impacting their overall QoL, primarily physical and behavioral functioning. Worse health outcomes were associated with frequent seizures, prolonged hospital stays for diagnosis and treatment, shunt infections, increased number of shunt catheters, and longer travel distances to medical facilities.

Impact of standardized care guidelines featuring next-day discharge on outcome, healthcare consumption, and patient healthcare experience in patients with idiopathic normal pressure hydrocephalus receiving ventriculoperitoneal shunts.

The aim of this study was to evaluate the effect of standardized care guidelines featuring next-day discharge on hospital length of stay (LOS), outcomes, patient experience, and healthcare consumption in patients receiving ventriculoperitoneal shunts (VPSs) for idiopathic normal pressure hydrocephalus (iNPH). This single-center population-based observational cohort study included 271 adult iNPH patients who underwent VPS surgery at Karolinska University Hospital. Groups were compared before and after the implementation of new standardized discharge guidelines. The primary outcome was the hospital LOS. Secondary outcomes included postoperative complications, patient experience, and frequency of unscheduled outpatient follow-up appointments. A total of 121 patients were treated with variable hospitalization periods. One hundred fifty patients were managed under the new guidelines stipulating next-day discharge. There was no significant difference in positive surgical outcome (66% vs 71%, p = 0.372) or rates of complication (p ≥ 0.066) between groups. The standardized guidelines group had a significantly shorter period of inpatient hospitalization (1 vs 2 days, p < 0.001) and demonstrated lower levels of unscheduled outpatient healthcare consumption (p < 0.001) while maintaining levels of positive patient experience (p = 0.828). Standardized discharge guidelines featuring next-day discharge are safe for iNPH patients undergoing VPS surgery, maintain the quality of the patient experience, and are an effective method for mitigating healthcare consumption in an expanding patient group.

Prompt closure versus gradual weaning of external ventricular drain for hydrocephalus following aneurysmal subarachnoid haemorrhage: a statistical analysis plan for the DRAIN randomised clinical trial

BackgroundInsertion of an external ventricular drain (EVD) is a first-line treatment of acute hydrocephalus caused by aneurysmal subarachnoid haemorrhage (aSAH). Once the patient is clinically stable, the EVD is either removed or replaced by a permanent internal shunt. The optimal strategy for cessation of the EVD is unknown. Prompt closure carries a risk of acute hydrocephalus or redundant shunt implantations, whereas gradual weaning may increase the risk of EVD-related infections.MethodsDRAIN (Danish RAndomised Trial of External Ventricular Drainage Cessation IN Aneurysmal Subarachnoid Haemorrhage) is an international multicentre randomised clinical trial comparing prompt closure versus gradual weaning of the EVD after aSAH. The primary outcome is a composite of VP-shunt implantation, all-cause mortality, or EVD-related infection. Secondary outcomes are serious adverse events excluding mortality and health-related quality of life (EQ-5D-5L). Exploratory outcomes are modified Rankin Scale, Fatigue Severity Scale, Glasgow Outcome Scale Extended, and length of stay in the neurointensive care unit and hospital. Outcome assessment will be performed 6 months after ictus. Based on the sample size calculation (event proportion 80% in the gradual weaning group, relative risk reduction 20%, alpha 5%, power 80%), 122 participants are required in each intervention group. Outcome assessment for the primary outcome, statistical analyses, and conclusion drawing will be blinded. Two independent statistical analyses and reports will be tracked using a version control system, and both will be published. Based on the final statistical report, the blinded steering group will formulate two abstracts.ConclusionWe present a pre-defined statistical analysis plan for the randomised DRAIN trial, which limits bias, p-hacking, and data-driven interpretations. This statistical analysis plan is accompanied by tables with simulated data, which increases transparency and reproducibility.Trial registrationClinicalTrials.gov identifier: NCT03948256. Registered on May 13, 2019.

Pediatric shunt failure in a resource limited Lower-Middle Income Country (LMIC) institution in La Paz, Bolivia.

Shunt failure is an undesirable but common occurrence following neurosurgical shunting for pediatric hydrocephalus. Little is known about the occurrence of failure in lower-middle income country (LMIC) settings in South America. The objective of this study was to evaluate shunt failure in the sole publicly funded pediatric hospital in La Paz, Bolivia, with limited resources. A retrospective review of all patients at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria"), was conducted to identify all patients whose index surgical shunting for hydrocephalus was performed between 2019 and 2023. Categorical, continuous, and shunt failure data were statistically summarized. A total of 147 unique pediatric patients underwent index ventriculoperitoneal shunting for hydrocephalus in the study period. There were 90 (61%) male and 57 (39%) female patients, with a median age of 2.2months at index shunting procedure. The most common surgical indications were congenital hydrocephalus (n = 95, 65%), followed by hydrocephalus secondary to congenital defect (n = 25, 17%) and tumor (n = 18, 12%). A total of 18 (12%) of patients experienced inpatient failure during index admission requiring surgical revision at a median time of 12.5days after index shunting. Postoperative imaging (OR 2.97, P = 0.037) and postoperative infection (OR 3.26, P = 0.032) during index admission both independently and statistically predicted inpatient failure. Of the 96 patients (65%) with postoperative follow-up, 16 (n = 16/96, 17%) patients experienced outpatient failure requiring readmission to hospital and surgical revision at a median time of 3.7months after discharge. Kaplan-Meier estimations of overall inpatient and outpatient failure in this cohort were 23% (95% CI 14-37) and 28% (95% CI 15-49), respectively. Both inpatient and outpatient shunt failures are significant complications in the management of pediatric hydrocephalus in La Paz, Bolivia. We identify multiple avenues to improve these outcomes which are institution-specific based on the review of these failures. Lessons learnt may be applicable to other similarly resourced institutions across South American LMICs.

Predictive factors and outcomes in treating shunt malfunctions: a case study of multiloculated hydrocephalus

Background. Endoscopic septostomy is a secure and reliable endoscopic for treating multiloculated hydrocephalus. The ventriculoperitoneal (VP) shunt procedure is known as the gold standard. However, shunt malfunction often occurs. The combination of these has been reported to reduce the incidence of recurrent malfunction and reestablish communication between isolated intraventricular compartments making a special ventricular cavity. Case presentation. A one-year-old child who had previously communicated hydrocephalus complained of vomiting, appeared agitated, and had difficulty falling asleep. The patient had a history of congenital diseases. The patient had VP shunt Keen dextra and sinistra fitted to manage the hydrocephalus before, but one side of the VP shunt was found to be malfunctioning. Physical examination revealed a sunset eye phenomenon with a head circumference of 48 cm dry and clean ventricular parietal shunt surgery scars. The findings of the multiloculated cystic lesions on the endoscopic, agenesis of the septum pellucidum, and dysgenesis of the corpus callosum. Discussion. The patient was scheduled for endoscopic cyst fenestrations surgery, endoscopic third ventriculostomy (ETV), VP shunt Kocher dextra low pressure, and aff VP shunt Keen dextra that was evaluated with preoperative and postoperative CT scans which showed the sulcus and gyrus prominent had improved, slightly open in fissure Sylvie, reduced size in ventricular (the average decrease was 5 cm3) that decreased intracranial pressure which improved the patient’s quality of life. Conclusion. Endoscopy septostomy and VP shunt are a great combination to treat multiloculated hydrocephalus and VP shunt malfunction.

Vaulting further: cranial vault expansion for craniocerebral disproportion without primary craniosynostosis.

Treatment of subjects with refractory idiopathic intracranial hypertension (IIH) or shunted hydrocephalus with chronic shunt complications is challenging. What is the role for cranial vault expansion, particularly utilizing posterior vault distraction osteogenesis (PVDO), in these cases? This study assesses medium-term efficacy of cranial vault expansion in this unique patient population. A retrospective review was conducted of patients who underwent cranial vault expansion from 2008 to 2023 at the Children's Hospital of Philadelphia. Subjects who did not have a diagnosis of primary craniosynostosis were included in the study. Demographic information, medical history, and perioperative details were collected from medical records. Primary outcomes were the rate of CSF diversion procedures and resolution of presenting signs and symptoms. Secondary outcomes were perioperative and 90-day complications and reoperation requirement. Among 13 included subjects, nine (69.2%) patients had a primary diagnosis of shunted hydrocephalus and 4 (30.8%) patients had IIH. Twelve (92.3%) subjects underwent posterior vault distraction osteogenesis (PVDO) and one (7.7%) underwent posterior vault remodeling (PVR). All 4 patients with IIH demonstrated symptomatic improvement following PVDO, including resolution of headaches, vomiting, and/or papilledema. Among 9 patients with shunted hydrocephalus, CSF diversion requirement decreased from 2.7 ± 1.6 procedures per year preoperatively to 1.2 ± 1.8 per year following cranial vault expansion (p = 0.030). The mean postoperative follow-up was 4.1 ± 2.1years and four (30.8%) patients experienced complications within 90days of surgery, including infection (n = 2), CSF leak (n = 1), and elevated ICP requiring lumbar puncture (n = 1). Four (30.8%) patients underwent repeat cranial vault expansion for recurrence of ICP-related symptoms. At most recent follow-up, 7 of 9 patients with shunted hydrocephalus demonstrated symptomatic improvement. Cranial vault expansion reduced intracranial hypertension-related symptomology as well as the rate of CSF diversion-related procedures in patients with refractory IIH and shunted hydrocephalus without craniosynostosis, and should be considered in those who have significant shunt morbidity.

Visual disorders in children with shunted hydrocephalus.

The introduction of shunt operations in neurosurgical practice gave a chance for life to these patients and significantly improved its quality. Along with its positive effect, surgical treatment is associated with a number of complications that, together with hydrocephalus itself, affect the subsequent development of shunted patients in the short and long term. In the long term, problems observed in shunted patients are mental retardation, cerebral palsy (CP), epilepsy, hearing and vision disorders. Visual disturbances are common in children with shunted hydrocephalus. These include reduced visual acuity, eye movement disorders, refractive anomalies, visual field defects, reduced color vision and strabismus, optic atrophy. The mechanism of visual disturbances is associated with damage to the oculomotor pathways, optic nerves and optic radiation, dilatation of the lateral ventricles, and damage to the periventricular white matter. Age at onset of hydrocephalus and ventricular dimension are important in the development of visual disturbances and placement of a shunting system can improve visual function. At the same time ophthalmic disturbances may be the first and only sign of shunt dysfunction and rapid normalization of elevated ICP preserves vision. Visual disturbances in patients with shunted hydrocephalus correlate with higher incidence of CP and epilepsy. They determine the children’s social integration and quality of life.

Decompressive craniotomy for severe traumatic brain injury: Our experience and review of literature

Introduction: Severe traumatic brain injury (TBI) is the most devastating injury affecting physical, mental, social and financial health of an individual and a society. The research, understanding and management of TBI is mainly focussed towards the secondary effects of the traumatic brain injury. Maintaining intracranial pressure within reasonable bounds is essential for successful TBI therapy, as an uncontrolled intracranial pressure (ICP) plays a major role in determining the course and prognosis of the injury. In general, ICP can be managed medically and/or surgically. In this article, we discuss our experience, the most recent understanding, and a method for managing ICP in traumatic brain injury. Material and Methods: This study comprised 350 patients with moderate to severe traumatic brain injury (TBI) who were treated by a single neurosurgeon at several institutions between 2005 and 2020. 76.6% (268) of the patients were men, and 64% (224) of the patients were under 60 years old. The most common mode of injury was road traffic accident followed by fall from height. The study excluded those patients with brain stem injuries, bilateral non-reacting pupils, and concomitant significant injuries in other body parts. All were first treated medically with appropriate resuscitation, hyper-osmolar therapy (mannitol, 3% saline), hyperventilation, and barbiturate coma as per the response and requirement. Surgical intervention was used for patients who did not respond to medical management. In addition, decompressive craniectomy (DC) was primarily performed on those whose GCS was less than 5 and who had reacting pupils, upon presentation. Results: Out of the 350 patients, 53.2% (186) had moderate TBI and 46.8% (164) had severe TBI. Due to failure of medical management, 30.5% (54) of moderate and 69.5% (123) of severe TBI underwent decompressive craniectomy in the form of bifrontal craniectomy in 18% (32), unilateral fronto-temporo-parietal craniectomy (hemicraniectomy) in 64% (113) , bilateral hemicraniectomy in 6% (11) and 12% (21) underwent limited fronto-temporo-parietal craniectomy. Decompressive craniectomy was not performed for posterior fossa. The data on outcome is very poor, inadequate and unreliable due to bad follow up. 5 years Follow up could be obtained only of 127 out of 350 (36%) patients and majority of these 69% (88) were moderately or severely disabled. Of those operated ones, only 27% (48) agreed for cranioplasty. 17% (30) had to undergo VP shunt for hydrocephalus. The group with severe traumatic brain injury (TBI) accounted for the majority of deaths (17%), with respiratory tract infections being the primary cause. Conclusion: Decompressive craniectomy is the sole option in medically refractory cases of traumatic intracranial hypertension, who continue to deteriorate clinically. Nevertheless, the benefit falls short of expectations, particularly with regard to functional recovery. However prompt and appropriate decompression in appropriately indicated patients has withstood the test of time and remains a widely accepted attempt at life saving for moderate-to-severe traumatic brain injury.

Comparison of Optic Nerve Sheath Diameter (ONSD) Measurements Obtained from USG Before and After Placement of Ventriculoperitoneal Shunt in Obstructive Hydrocephalus as a Surrogate Marker for Adequacy of Shunt Function: A Prospective Observational Study.

Introduction Optic nerve sheath diameter (ONSD) measured using ultrasonography has been widely used as a surrogate marker of elevated intracranial pressure. However, literature is sparse on the correlation between ONSD and ventriculoperitoneal (VP) shunt function, especially in adults with hydrocephalus. Our study was designed to assess the correlation between ONSD measured using ultrasonography before and 12 hours after VP shunt placement and the success of VP shunt placement assessed using computed tomography (CT) of the brain. Materials and Methods Fifty-one patients between 16 and 60 years of age, with obstructive hydrocephalus scheduled for VP shunt surgery were included in this prospective, observational study. ONSD measurements were obtained from both eyes prior to induction of anesthesia, immediately after the surgery, and at 6, 12, and 24 hours after the surgery. An average of three readings was obtained from each eye. Cerebrospinal fluid (CSF) opening pressure was noted after entry into the lateral ventricle. Noncontrast CT (NCCT) brain was obtained 12 hours after the surgery and was interpreted by the same neurosurgeon for signs of successful VP shunt placement. Results There was a significant reduction in ONSD in the postoperative period compared to ONSD measured preoperatively. The average ONSD (mean ± standard deviation) measured prior to induction of anesthesia, immediately after the surgery, and at 6, 12, and 24 hours after the surgery was 5.71 ± 0.95, 5.20 ± 0.84, 5.06 ± 0.79, 4.90 ± 0.79, and 4.76 ± 0.75 mm, respectively. The mean CSF opening pressure was 19.6 ± 6.9 mm Hg. Postoperative NCCT brain revealed misplacement of the shunt tip in only one patient. Conclusion ONSD measured using ultrasonography may be used as a reliable indicator of VP shunt function in adults with obstructive hydrocephalus.

Classification of the relationship between suprasellar arachnoid cyst and hydrocephalus based on treatment modalities: shunting versus neuroendoscopic approaches.

Children diagnosed with suprasellar arachnoid cysts often concurrently have hydrocephalus. This study aims to classify the relationship between suprasellar arachnoid cysts and hydrocephalus, discussing surgical strategies-shunting or neuroendoscopic approaches-and their sequence, based on this classification. A retrospective analysis was conducted on 14 patients diagnosed with suprasellar arachnoid cysts and hydrocephalus, treated surgically by the first author between January 2016 and December 2020. Clinical features, radiological findings, surgical strategies, and outcomes were reviewed. The classification of the relationship between the suprasellar arachnoid cysts and hydrocephalus was developed and illustrated with specific cases. Recommendations for future surgical management based on this classification are provided. We classified the relationship between suprasellar arachnoid cysts and hydrocephalus into three categories. SACH-R1, the direct type, represents cases where the cysts cause obstructive hydrocephalus. Here, neuroendoscopic ventriculocystocisternostomy (VCC) effectively treats both conditions. SACH-R2, the juxtaposed type, involves concurrent occurrences of cysts and hydrocephalus without a causative link. This is further subdivided into SACH-R2a, where acute progressive communicating hydrocephalus coexists with the cyst, initially managed with a ventriculoperitoneal shunt, followed by VCC upon stabilization of hydrocephalus; and SACH-R2b, where the cyst coexists with chronic stable communicating hydrocephalus, first addressed with VCC, followed by monitoring and potential secondary shunting if needed. Key factors differentiating SACH-R2a from SACH-R2b include the patient's age, imaging signs of fourth ventricle and cisterna magna enlargement, and the rapid progression or chronic stability and severity of hydrocephalus symptoms. SACH-R3, the reverse type, describes scenarios where shunting for hydrocephalus leads to the development or enlargement of the cyst, managed via neuroendoscopic VCC with precautions to prevent infections in existing shunt systems. The simultaneous presence of suprasellar arachnoid cysts and hydrocephalus requires a nuanced understanding of their complex relationship for optimal surgical intervention. The analysis and classification of their relationship are crucial for determining appropriate surgical approaches, including the choice and sequence of shunting and neuroendoscopic techniques. Treatment should be tailored to the specific type identified, rather than blindly opting for neuroendoscopy. Particularly for SACH-R2a cases, we recommend initial ventriculoperitoneal shunting.

Comparison of endoscopic third ventriculostomy versus cerebrospinal fluid shunt procedures for the treatment of pediatric hydrocephalus in Taiwan.

Pediatric hydrocephalus is the most common cause of surgically treatable neurological disease in children. Controversies exist whether endoscopic third ventriculostomy (ETV) or cerebrospinal fluid (CSF) shunt placement is the most appropriate treatment for pediatric hydrocephalus. This study aimed to compare the risk of re-operation and death between the two procedures. We performed a retrospective population-based cohort study and included patients younger than 20-years-old who underwent CSF shunt or ETV for hydrocephalus from the Taiwan National Health Insurance Research Database. A total of 3,555 pediatric patients from 2004 to 2017 were selected, including 2,340 (65.8%) patients that received CSF shunt placement and 1215 (34.2%) patients that underwent ETV. The incidence of all-cause death was 3.31 per 100 person-year for CSF shunt group and 2.52 per 100 person-year for ETV group, with an adjusted hazard ratio (HR) of 0.79 (95% confidence interval [CI] = 0.66-0.94, p = 0.009). The cumulative incidence competing risk for reoperation was 31.2% forthe CSF shunt group and 26.4% forthe ETV group, with an adjusted subdistribution HR of 0.82 (95% CI = 0.70-0.96, p = 0.015). Subgroup analysis showed that ETV was beneficial for hydrocephalus coexisting with brain or spinal tumor, central nervous system infection, and intracranial hemorrhage. Our data indicates ETV is a betteroperative procedure for pediatric hydrocephalus when advanced surgical techniques and instruments are available.

Ventriculoperitoneal shunt failures at Red Cross War Memorial Children’s Hospital

IntroductionVentriculoperitoneal shunt (VP shunt) insertion is one of the mainstays of treatment of hydrocephalus and although very effective, a high rate of shunt failure persists globally. The purpose of the study was to quantify the ventriculoperitoneal shunt failure rate at Red Cross War Memorial Children’s Hospital (RCWMCH) and assess potential factors contributing to shunt failures.MethodsA retrospective review of VP shunts done at RCWMCH between August 2015 through December 2019 was performed. Operative notes, discharge summaries and patient folders were reviewed to collect information about patient age, aetiology of hydrocephalus, index vs revision shunt, shunt system and other noticeable variables. Overall shunt failure was recorded. Univariate and multivariate models were used to determine causal relationship.ResultsFour hundred and ninety-four VP shunt operations were performed on 340 patients with 48.8% being index shunts and 51.2% revision shunts. The average patient age was 3.4 months. The total VP shunt failure rate over the study period was 31.2%, with a 7.3% infection rate, 13.6% blockage and 3.6% disconnection rate. The most common aetiologies were post-infectious hydrocephalus 29.4%, myelomeningocele 19.7% and premature intraventricular haemorrhage 14.1%. Orbis-sigma II (OSVII), distal slit valves and antibiotic-impregnated catheters were used most frequently. Failure rates were highest in the revision group, 34.7% compared to 27.3% in index shunts. Sixty-five percent (65%) of the head circumferences measured were above the + 3 Z score (> 90th centile).ConclusionVP shunt failure occurs most commonly in revision surgery, and care should be taken at the index operation to reduce failure risk. Surgeon level, duration of surgery, aetiology of hydrocephalus and shunt system used did not influence overall failure rates. A closer look at larger head circumferences, their effect on shunt systems and the socio-economic factors behind late presentations should be investigated further in the future.

Endoscopic Third Ventriculostomy versus Cerebrospinal Fluid Shunting in Hydrocephalus associated with Posterior Fossa Lesions in Adults; Comparative study

Endoscopic Third Ventriculostomy versus Cerebrospinal Fluid Shunting in Hydrocephalus associated with Posterior Fossa Lesions in Adults; Comparative study

Approaching an undetermined diagnosis in the aftermath of rhombencephalitis: A case report

A 49-year-old male patient manifested acute onset increased imbalance, quadriparesis, and speech impairment 1 month after undergoing ventricular-peritoneal shunt for normal pressure hydrocephalus (although magnetic resonance imaging [MRI] of the brain with contrast was otherwise normal), which showed improvement afterward. He had hypercalcemia and elevated erythrocyte sedimentation rate. Repeat brain MRI revealed pachymeningitis coupled with rhombencephalitis, while cerebrospinal fluid study unveiled only increased protein level without evidence of active infection. Given these findings, neurosarcoidosis was preliminarily considered a plausible cause of the recent clinical manifestations, and the patient was prescribed methylprednisolone, which led to significant improvement. However, the steroid treatment was discontinued on the revelation that the patient grappled with severe sepsis. Despite an initial improvement following a post-management of sepsis, his condition deteriorated, and he became lost to follow-up after 4 months of initial presentation. An infective etiology was ruled out since his condition improved with steroid. Precluding vasculitis or demyelinating disorder left the physicians with primary central nervous system (CNS) lymphoma or sarcoidosis as a proper diagnosis based on the fact that the patient experienced deterioration when steroid was excluded from the treatment regimen. This case study portrays a need to conduct a more specific and elaborate investigation, driven by a strong perception to both primary CNS lymphoma and sarcoidosis, to optimize clinical diagnosis, which facilitates the formulation of an appropriate treatment regimen.

Efficacy and Complications of Lumboperitoneal Shunt for Idiopathic Normal Pressure Hydrocephalus in Elderly Patients: A Systematic-review and Meta-analysis (P11-9.001)

Efficacy and Complications of Lumboperitoneal Shunt for Idiopathic Normal Pressure Hydrocephalus in Elderly Patients: A Systematic-review and Meta-analysis (P11-9.001)